Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Child Adolesc Psychiatr Nurs. Author manuscript; available in PMC Feb 1, 2012.
Published in final edited form as:
PMCID: PMC3076318

The Role of Family Phenomena in Posttraumatic Stress in Youth

Catherine C. McDonald, PhD, RN, Ruth L. Kirschstein NRSA Postdoctoral Fellowcorresponding author and Janet A. Deatrick, PhD, FAAN, Associate Professor and Associate Director



Youth face trauma that can cause posttraumatic stress (PTS).


1). To identify the family phenomena used in youth PTS research; and 2). Critically examine the research findings regarding the relationship between family phenomena and youth PTS.


Systematic literature review in PsycInfo, PILOTS, CINAHL, and MEDLINE. Twenty-six empirical articles met inclusion criteria.


Measurement of family phenomena included family functioning, support, environment, expressiveness, relationships, cohesion, communication, satisfaction, life events related to family, parental style of influence, and parental bonding. Few studies gave clear conceptualization of family or family phenomena. Empirical findings from the 26 studies indicate inconsistent empirical relationships between family phenomena and youth PTS, though a majority of the prospective studies support a relationship between family phenomena and youth PTS. Future directions for leadership by psychiatric nurses in this area of research and practice are recommended.

Keywords: Family phenomena, posttraumatic stress, trauma, violence, youth

Youth are faced with traumatic events in the form of natural disasters, life-threatening or chronic illnesses, major acts of violence, trauma, and in everyday events such as witnessing a knifing, shooting, or being jumped on the street (National Institute of Mental Health, 2010). These events can be traumatic for children and adolescents and can elicit pathologic stress responses indicative of posttraumatic stress (PTS). As psychiatric nurses working with youth know, PTS broadly refers to the persistent symptom clustering of intrusive recollections/re-experiencing, avoidant/numbing symptoms, and hyperarousal symptoms (American Psychiatric Association [APA], 2000). Posttraumatic stress disorder (PTSD) is the clinical diagnosis that includes this same symptom clustering but has more stringent diagnostic criteria. The term PTS broadly captures the more general clinically relevant subdiagnostic symptoms, as well as the symptom clustering meeting diagnostic criteria for PTSD (Kazak et al., 2006).

Responses to traumas are influenced by the severity and duration of the trauma, as well as the immature developmental state of the brain in youth (National Institute of Health, 2005; Pynoos, Steinberg, Ornitz, & Goenjian, 1997; Pynoos, Steinberg, & Piacentini, 1999). The context of family during childhood and adolescence can also influence the response to trauma (Kazak et al., 2006; Kiser & Black, 2005). Consistent literature indicates that family proximity to trauma (e.g. family member dies in event) influences youth PTS (Holbrook et al., 2005; Langeland and Olff, 2008; Scheeringa, Wright, Hunt, & Zeanah, 2006; van der Kolk, 2003; van der Kolk et al., 1996). Likewise, parental mental health can also affect youth PTS (Barakat et al., 1997; Boyer, Ware, Knolls, & Kafkalas, 2003; Kiliç, Özgüven, & Sayil, 2003; Laor, Wolmer, & Cohen, 2001; Meiser-Stedman, Yule, Dalgleish, Smith, & Glucksman, 2006; Ozono et al., 2007). What deserves further exploration is the understanding of how studies have examined family phenomena in association with youth PTS. Family phenomena can be defined as processes related to the nature and characteristics of family life and family groups used by clinicians, researchers, and theorists. Given family phenomena as a potential point of intervention for psychiatric nurses, the nature of family phenomena in youth PTS deserves investigation.

The purpose of this critical review is 1). To identify the family phenomena used in youth PTS research; and 2). Critically examine the research findings regarding the relationship between family phenomena and youth PTS. This review will specifically examine how family phenomena have been measured in studies with youth PTS, what is empirically known about family phenomena in youth PTS, and how psychiatric nurses can provide leadership to future research to improve upon the current state of the science.

For this broad examination, a comprehensive perspective on PTS is needed, one that incorporates a transdisciplinary and cross-cultural perspective regarding trauma beyond a singular focus. The scope of trauma for PTS is not narrow and can encompass child or sexual abuse, exposure to war or family violence, unintentional injuries, stress related to traumatic medical experiences, and community violence. (National Child Traumatic Stress Network, 2010). The nature and severity of the trauma can influence a stress response, just as youth responses to events vary (Terr, 1991; van der Kolk, 2003). Therefore, a non-categorical view of trauma in the context of youth PTS and family phenomena for this review may elicit a better understanding of what family phenomena have been examined in relationship to youth PTS. For the purposes of this manuscript, the term youth encompasses both children and adolescents; the term PTS will be inclusive of the symptoms indicating the diagnosis of PTSD, subdiagnostic symptoms of PTSD, and pediatric medical traumatic stress. The term PTSD will only be used when reporting on studies that specifically indicate differences between those with and without a clinical diagnosis.


A literature search in February 2010 in PsycInfo, PILOTS, CINAHL, and MEDLINE was conducted with no date restriction using the key words: ‘posttraumatic stress,’ ‘child(ren),’ ‘adolescent(ce),’ ‘youth,’ ‘family functioning,’ ‘family support,’ ‘family cohesion,’ ‘family environment,’ and ‘family structure.’ Inclusion criteria: peer-reviewed journal articles in the English language; and studies assessing relationships between youth PTS and family phenomena (e.g. functioning, support, or environment). Studies that only examined proximity or involvement of a family member in the trauma were excluded. The search yielded 26 peer-reviewed journal articles of quantitative studies examining the role of family phenomena in youth PTS. Articles with an “*” in the reference list indicate articles from this search. Studies were analyzed by conceptual definition and measurement of family phenomena, samples surveyed in the 26 studies, conceptual framework and definition of the family, empirical relationships between family phenomena and youth PTS, data analysis strategies, and cultural considerations. Table 1 describes each study by sample, trauma, family phenomena and measure, and relevant findings.

Table 1
Description of Studies


Conceptual Definitions of Family Phenomena

In the 26 studies, the following family phenomena were examined: family functioning, support, environment, expressiveness, relationships, cohesion, communication, satisfaction, life events related to family, parental style of influence, and parental bonding (see Table 1 for associated studies). All studies cited the phenomena of interest in the literature review or introduction. Eight studies described the models the instruments were based on (Alderfer et al., 2009; Barakat et al., 1997; Boyer, Hitelman, et al., 2003; Boyer, Ware, et al., 2003; Burton et al., 1994; Kazak et al., 1997; Max et al, 1998; Ozono et al., 2007). Although almost all studies explained the instruments, most studies did not give explicit conceptual definitions of the family phenomena prior to instrument description.

Measurement of the Role of Family Phenomena

Eighteen different standardized instruments were used to assess eleven family phenomena. The Family Environment Scale (FES) (Moos & Moos, 1986), including the shortened form (Family Relations Index (FRI)), was the instrument most often used (n=8). One study measured family support by family size and mother’s presence in the home (Overstreet, Dempsey, Graham, & Moely, 1999). Measurement of family environment and family functioning intersected. Family environment was consistently measured by the FES, but family functioning was measured by various instruments, including: FACES II, III, and IIIA, Family Assessment Device (FAD) (Epstein, Baldwin, & Bishop, 1983), Family Apgar (Smilkstein, 1978), Family Life Scale (FLS) (Fisher, Ransom, & Terry, 1993), the McMaster Structured Interview of Family Functioning (Miller et al., 1994), Family Functioning Questionnaire (FFQ) (McFarlane, 1987), and the FES (including the FRI). Overlap of the FES measuring family functioning and environment indicated that the two phenomena did not reflect two distinct variables for measurement. The FES was designed to assess interpersonal relationships and overall social environment of the family, and could therefore measure a broad array of family phenomena, such as family functioning (Moos & Moos, 1986). For example, Meiser-Stedman and colleagues (2006) noted that aspects of the youth’s family environment included family functioning.

Samples in the Studies

The reference traumas for PTS in the sample of the 26 studies included cancer, spinal cord injury, general violence exposure and trauma, cardiac surgery, home fire, family violence, political violence, natural disasters, sexual abuse, and traumatic brain injury. Youth ranged from ages 5 to 24, from various racial and ethnic backgrounds. Seven different countries were represented: most prevalent was the United States (18 studies), likely due to the bias of inclusion criteria for English language articles only. Fifteen studies included mothers, eleven included fathers, one included siblings, and one specified inclusion of legal guardians in the sample. Six studies had longitudinal designs (Greenberg & Keane, 2001; Laor, et al., 2001; Max et al., 1998; Meiser-Stedman, et al., 2006; Schreier, Ladakakos, Morabito, Chapman, & Knudson, 2005; Zatzick et al., 2008) and the remaining had cross-sectional designs.

Conceptual Framework and Definition of the Family

Eight out of the 26 studies outlined using a conceptual framework and only one study gave an explicit definition of the family. Ozono and colleagues (2007) used a family systems framework, stating its importance for supporting family of childhood cancer survivors. Brown, Madan-Swain, and Lambert (2003) outlined the use of a family system framework nested in the social-ecological model (Bronfenbrenner, 1979). Frameworks for adaptation or adjustment to stress and trauma guided six studies (Alderfer, Navsaria, & Kazak, 2009; Barakat et al., 1997; Boyer, Hitelman, Knolls, & Kafkalas, 2003; Burton, Foy, Bwanausi, & Johnson, 1994; Greenberg & Keane, 2001; Harris & Zakowski, 2003). For example, Barakat and colleagues (1997) used models of PTS suggesting that responses are influenced by nature and severity of trauma, social support and coping resources, and child characteristics. One study explicitly defined family: Greenberg and Keane (2001) defined family as mother, father, siblings, aunts, and grandparents. Seven studies reported family living arrangement of the youth (see Table 1 for details) (Alderfer et al., 2009; Barakat et al., 1997; Boyer, Ware, et al., 2003; Burton et al., 1994; Dixon, Howie, & Starling, 2005; Halloran, Ross, & Carey, 2002; Linning & Kearney, 2004). Although not equivalent to the definition of family, except when referring to those related to household boundaries, statistics on family living arrangements gave context to the data.

Empirical Relationships between Family Phenomena and Youth PTS

Five studies found that elements of family functioning and family environment correlated with PTS in youth (r strength=.22-.64; directionality of relationship depended on phenomena measured; trauma exposure included spinal cord injury, violence, trauma, and SCUD missile attack) (Boyer, Hitelman, et al., 2003; Boyer, Ware, et al., 2003; Burton et al., 1994; Laor et al., 2001; Overstreet et al., 1999). Khamis (2005) found significant differences between Palestinian youth with PTSD and those without PTSD in the family environment (t (998) =−3.94, p < .0001) and parental style of influence (t (998) =−2.76, p < .006). Here, youth with PTSD had more reports of anxiety in the home environment and harsher discipline. In addition, for physically or sexually maltreated youth, those with PTSD had scores on family cohesion far below normative values; independence was also below normative values in PTSD and non-PTSD groups (Linning & Kearney, 2004). Ozono and colleagues (2007) found that youth cancer survivors with severe symptoms of PTS reported lower levels of family functioning with respect to roles and affective responsiveness than youth with less severe PTS (p<.05). Pelcovitz and colleagues (1998) found that youth with history of cancer and PTSD saw their families as significantly more chaotic that those without PTSD. In a sample of cancer survivors, Alderfer and colleagues (2009) found that youth with PTSD had families with poorer problem-solving, affective response, and affective involvement (p<.05). Also, 75% of the youth with PTSD had poorly functioning families and were five times as likely to come from families with poor functioning.

Investigators in five other studies, however, found that the bivariate relationships of family functioning, family environment, and family support with PTS were not significant (pediatric cancer, trauma, parental cancer, earthquake, media exposure to 9/11, and rocket attacks) (Brown et al., 2003; Dixon et al., 2005; Harris & Zakowski, 2003; Kasler, Dahan, & Elias, 2008; Kiliç, Özgüven, & Sayil, 2003). Additionally, in a sample of cancer survivors, Kazak and colleagues (1997) found significant correlations for youth PTS and mother’s family satisfaction (r=−.24); but mother’s report of general family functioning or communication and father’s report of general family functioning, communication, or satisfaction were not significant. Otto and colleagues (2007) also found in regards to media exposure to 9/11, family conflict and cohesiveness were not associated with PTS, but family expressiveness was associated with lower PTS (p<.05).

In seven studies using regression analyses, family phenomena did not contribute to the variance in youth PTS (traumas including pediatric cancer, cardiac surgery, trauma, earthquake, and sexual victimization) (Barakat et al., 1997; Brown et al., 2003; Connolly, McClowry, Hayman, Mahony, & Artman, 2004; Dixon et al., 2005; Kiliç et al., 2003; Koverola, Proulx, Battle, & Hanna, 1996; Ozono et al., 2007). Overstreet and colleagues (1999) found that family support did not moderate the effects of community violence exposure on PTS. These studies using regression analyses indicated that while controlling for other variables, family phenomena were not consistently associated with youth PTS.

Two other studies found in regressions, however, that family environment and functioning contributed to the variance in youth PTS (Burton et al., 1994; Khamis, 2005). Halloran and colleagues (2002) also found in their sample of psychiatric in-patient youth, for females only, a structured family was associated with increased odds of PTS (odds ratio 3.21): behaviors associated with family structure (control, achievement, morality, and organization) may help males to be successful, but have a detrimental effect for females when dealing with a trauma.

The majority of prospective studies indicated significant relationship between family phenomena and youth PTS. Greenberg and Keane (2001) found that youth satisfaction with family support measured at baseline contributed to later PTS in youth exposed to a home fire. Max and colleagues (1998) also found that pre-injury level of family functioning predicted PTS symptoms in youth with traumatic brain injury. Laor and colleagues (2001) found that in youth exposed to a SCUD missile attack, family functioning at 30 months correlated with PTS at 5 years in residentially displaced children; the relationship did not hold true for residentially stable children. Two studies had prospective designs but analyzed relationships between family phenomena and youth PTS cross-sectionally (Schreier et al., 2005; Meiser-Stedman, et al., 2006). Schreier and colleagues (2005) found that youth exposed to mild to moderate trauma (excluding physical and sexual abuse, head injuries, and burns) rating their family as high achievement orientated also tended to have higher symptoms of PTS (r= .26–.52); increased expressiveness in families potentially mitigated the effects of PTS (r= −.24– −.28). Meiser-Stedman and colleagues (2006) found irritable distress and maternal overprotection correlated with PTS symptoms (r= .38–.44). Alternatively, Zatzick and colleagues (2008), found that PTS (as an independent variable) was not associated longitudinally with family cohesion (as a dependent variable) in youth cancer survivors.

Data Analysis

Nine studies used multiple participants for data reporting, including the youth incurring the trauma, as well as mothers, fathers, and siblings (Alderfer et al., 2009; Barakat et al., 1997; Boyer, Hitelman, et al., 2003; Boyer, Ware, et al., 2003; Brown et al., 2003; Harris & Zakowski, 2003; Kazak et al., 1997; Kiliç et al., 2003; Ozono et al, 2007). Six studies used only one member of the family in reporting some data, even though the sample had multiple family members available (Khamis, 2005; Laor et al., 2001; Meiser-Stedman et al., 2006; Otto et al., 2007; Pelcovitz et al., 1998; Schreier et al., 2005). One study was not entirely clear about who reported on the family phenomena measure (Connolly et al., 2004). All other studies had only the youth with the reference trauma in the sample, and thus had only single reporting.

Four studies with reports from multiple family members did not account for intra-familial correlation in data analysis (Barakat et al., 1997; Brown et al., 2003; Harris & Zakowski, 2003; Kazak et al., 1997). Others addressed multiple family members’ reporting in analysis. Two studies, both reporting on the same sample, computed the average scores of family functioning for mothers, fathers, and youth for analysis (Boyer, Hitelman, et al., 2003; Boyer, Ware, et al., 2003). Alderfer and colleagues (2009) also used average scores across family members. Other methods include paired analyses (for couples) and intercorrelations among family members (Kiliç et al., 2003; Ozono et al., 2007). One study by Otto and colleagues (2007) had multiple siblings related to one mother, but only had the mother report on family support. They used generalized equation modeling, stating that multiple siblings from one family could not be considered independently sampled (Rosenbaum et al., 1991; 2000).

International Context and Cultural Considerations

International context and culture emerged as necessary considerations when examining the role of family phenomena. For example, Khamis (2005) created a set of instruments specifically for a sample of Palestinian youth called the Family Ambiance Scale (FAS), the Child Psychological Maltreatment Scale (CPM), and the Harsh Discipline Scale (HDS). These instruments, developed for the cultural nuances in the sample of Palestinian youth, point towards the need for cultural considerations. The FAS had two factors separating apprehension and fear of communicating with the father, from apprehension and fear of communicating with the mother and siblings. The CPM was designed specifically to assess “repeated patterns of parental behavior that conveyed to children that they were worthless, flawed, unloved, unwanted, endangered or only of value in meeting another’s needs in the context of the Palestinian culture” (Khamis, 2000, p.85). Additionally, the HDS used phrases such as obedience and coercive punishment that may not translate across cultures. Kiliç and colleagues (2003) noted the validity and reliability of the Turkish version of the FAD, and spoke to the vulnerability of their sample that experienced two high magnitude earthquakes in a short period of time. With youth exposed to a SCUD missile attack in Israel, Laor and colleagues (2001) drew their sample from families living in the same neighborhood. Kasler and colleagues (2008) compared youth living in two different towns in Israel: one affected by rocket attacks and one that was not. Ozono and colleagues (2007) also noted the reliability and validity of their translated version of different measures.


Key Findings

This review indicates that studies have examined a vast array of family phenomena in relation to youth PTS. Few studies clearly delineate a conceptual definition of the family phenomena of interest. The empirical research findings in the 26 studies relative to the relationship between family phenomena and PTS in youth are mixed. Some studies found that family phenomena is associated with youth PTS when correlations or comparisons between high and low PTS are analyzed. The regression analyses, however, often did not support the predictive relationship between family phenomena and PTS in youth exposed to varied traumas (e.g. pediatric cancer, cardiac surgery, and violence). The prospective studies in this review, however, favored significant relationships between family phenomena and youth PTS. Prospective studies provide an important methodology by which to examine these critical variables of interest and give a clear direction for psychiatric nurses.

PTS is not a culture-bound phenomenon (Ruchkin et al., 2005). The cultural and international variation in the studies analyzed in this review is important. In this sample, trauma exposure in different geographic populations varies. The trauma and stress of a chronic illness can occur in any country, but the likelihood of earthquakes and political violence is more prevalent in some regions than others. The global perspective of this analysis indicates that PTS is not solely linked with one type of trauma, nor is the role of family phenomena in PTS across geographic regions and culture fully understood. International context and culture influence family and must be considered when evaluating family phenomena and youth PTS. Beliefs about trauma are often shaped by cultural meaning (e.g. religious conflict; natural disasters; severe childhood illness). The normative (i.e. healthy response to a bad event) and pathological adjustment (i.e. prolonged and severe avoidance, intrusive, and hyper-arousal symptoms) associated with PTS occurs across cultures and populations (APA, 2000; Foa, 1997; Horowitz, 1986; Kassam-Adams, 2006).


This review examined all types of traumas, so the overall findings may be limited. No one type of trauma exposure (e.g. injury or cancer survivorship), however, indicated that family phenomena consistently related to youth PTS. Given that youth experience many different types of traumas, this review sought to give a broad perspective of the literature. In doing so, the age range of the youth in the studies was wide (5–24) but reflects the diversity of the literature on youth PTS. Likewise, the 26 studies focused on many different family phenomena. This speaks to the breadth of the literature on family science, though comparison across studies may have limitations. Even though the focus of this review was wide, a general understanding of the literature in the context psychiatric nursing provides important direction for future research and eventual translation to practice.

A limitation in sample of these 26 studies included small sample sizes and lack of variation in key variables in some studies. Seventeen studies had less than 100 youth in the specified reference trauma. Even though studies employed different statistical analyses strategies to determine results, there is potential lack of statistical power to detect effect sizes associated with family phenomena with small sample sizes; some studies mentioned this in their own limitations (e.g. Meiser-Stedman et al., 2006; Ozono et al., 2007). The homogeneity in reporting of key variables by participants in given samples also presents a limitation. Dixon and colleagues (2005) looked at female juvenile defenders and found that most of the sample had poor family functioning. In contrast, Connolly and colleagues (2004) found that most of the families with a child undergoing cardiac surgery reported high levels of cohesiveness in the family. Both studies attributed their lack of statistical significance in their findings to the homogeneity in the sample for these variables. These disparate examples both share the common feature of how little variation in a key variable can impact analyses.

Another major limitation in the sample of studies is that of study design and data analysis. Lack of conceptualization of these various family phenomena in some studies prior to operationalization makes it difficult to compare studies across youth PTS. Most study designs were cross-sectional. With cross-sectional data, temporal sequence of events is unclear and the cyclical nature of family phenomena and mental health may not be well elucidated. Given that changes in family functioning are difficult to discern over time (Kazak et al., 1999), longitudinal studies that assess PTS changes over time can be very informative, as they can take into account directionality of relationships while the role of the family potentially remains constant There is also a potential developmental component to the emergence of PTS symptoms, as older youth may have a stronger association with PTS than younger (Hobbie et al., 2000). Given that symptoms of PTS can change over time, repeated measures may be effective. There are challenges with prospective study designs with multiple data collections points, yet further investigating PTS in youth longitudinally is critical.

Even though multiple family members were surveyed in some studies, not all accounted for intra-familial correlation in analyses. Indeed, there are longstanding challenges associated with family data (Fischer, Kokes, Ransom, Phillips, & Rudd, 1985; Uphold & Strickland, 1989). When family phenomena data are available from multiple family members, however, it is crucial to address intra-familial correlations because data from multiple family members are not independent (Kashy & Snyder, 1995; Knafl et al., 2009). Studies should outline a justification as to why or why not interfamilial correlation was taken into account.

Gaps in Knowledge and Recommendations

Psychiatric nurses can play major role in not only conducting research sensitive to the issues raised in this critical review, but also as clinical partners in the design and conduct of research. A clear gap in the knowledge is the conceptualization of family phenomena in relation to youth PTS. The lack of definitions associated with family phenomena likely contributes to the inconsistent relationships between family phenomena and youth PTS, and could be important in attenuating risk and development of PTS. Yet, this is a clear area where psychiatric nurses can provide strong direction. Psychiatric nurses must have a clear and appropriate conceptualization of their phenomena of interest in their research and a strong conceptual linkage to measurement. If family phenomenon is not clearly delineated, measures employed may not be capturing the intended phenomenon of interest. For example, if investigators believe that the family makes a difference due not only to cohesion but the overall environment, selection of family measure may include the FES instead of a measure that describes more intrafamily processes.

Psychiatric nurses’ knowledge of risk and protective factors that may contribute to the development of youth PTS within the context of the family can also make valuable contributions to future studies. The role of peers, school, and community in relationship to family phenomena may help to better describe the development of PTS in youth. Examining these factors in community dwelling youth may help to increase heterogeneity and generalizability of study findings. Future quantitative studies need to continue to use reliable and valid instruments to assess the role of the family with attention to sample size to ensure adequate power, and study design and analytical strategies to answer questions of interest. Intra-familial correlation needs to be taken into account when appropriate with multiple family respondents. Finally, qualitative studies may indicate further knowledge about the role of the family that may not be captured in a quantitative instrument. Psychiatric nurses can draw from the current state of the science of the role of the family and youth PTS to improve research and practice. Psychiatric nurses with both research and clinical agendas can make valuable contributions to all of these areas of concern.

The findings from these 26 studies add to knowledge of family phenomena and help to inform future directions for nursing science. Though most studies were not from the discipline of nursing, the findings are relevant to psychiatric nursing research and practice. Caring for youth in the context of the family is part of psychiatric nursing practice. The findings can inform not only future descriptive research, but interventions and practice which aim to improve the health and well-being of youth and families. For example, on the family level, cultural meaning/beliefs about trauma and transmission within the family system require examination. In the area of medical trauma specifically related to cancer, the Family Illness Beliefs Inventory (FIBI) constructed by Kazak and colleagues can be used to identify beliefs about childhood cancer that can then potentially be reframed with family systems cognitive behavioral approaches in order to prevent and treat PTS (Kazak et al., 2004; 2005; Stehl et al., 2009).

Future studies that examine youth with cancer, spinal cord injury, or other chronic illnesses, PTS, and family phenomena could benefit from the use of instruments that are specific to the management of chronic illness by the family, such as the Family Management Measure (FaMM) (Knafl et al., In Press). The FaMM has not been used in the context of youth PTS and family phenomena, but has potential to add to the science. Data from the FaMM contributes to the ability to understand more fully family functioning in the context of childhood chronic conditions, rather than trying to examine family functioning without the context of the illness. With the FaMM, measuring how the family manages the chronic illness in relation to family functioning and youth PTS may illuminate potentially important findings that are useful in nursing research and practice. By gathering knowledge about areas of family management that may specifically relate to PTS, nursing science can target both research and practice to improve mental health outcomes in youth.


Youth response to trauma such as political violence, injury, or life-threatening illness is important to nursing research and practice related to the mental health and well-being of youth. The role of the family is an important facet to physical and psychosocial growth and development for infants, children, and adolescents. At this point in the literature, there are inconsistent findings related to the role of family phenomena and PTS in youth, though prospective studies favor relationships between family phenomena and youth PTS exist. Discrepancies point towards an imperative focus in research to further understand the relationship of these factors. How youth respond to trauma and stress can have a large impact on long term psychosocial outcomes. Psychiatric nurses are well-positioned to foster healthy outcomes in young people faced with trauma and stress. Psychiatric nurses are actively engaged in caring for youth in the context of the whole family, and research and interventions need to continue to look further into the role of the family in PTS. Given that youth exist with the context of the family, understanding and providing support for the role of the family is also a necessity when examining potential areas for research and practice. Family is an important part of the holistic care of youth for psychiatric nurses. Targeted, effective interventions involving family and youth PTS should be addressed through careful research and practice.


This research was supported by Award Number F31NR011107 (PI: Catherine C. McDonald) from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. This research was also supported by National Institutes of Health/National Institute of Nursing Research T32 Research on Vulnerable Woman, Children and Families (2T32NR007100). Catherine C. McDonald is currently a NRSA Postdoctoral Fellow, Research on Vulnerable Women, Children, and Families (2T32NR007100).

Contributor Information

Catherine C. McDonald, University of Pennsylvania, School of Nursing, Center for Health Equity Research, 2L, 418 Curie Blvd., Philadelphia, PA 19104, Telephone: 215-898-1799 (via Dr Janet Deatrick), FAX: 215-573-9193 (via Dr Janet Deatrick)

Janet A. Deatrick, Center for Health Equity Research, University of Pennsylvania School of Nursing, Room 223 (2L) Claire M. Fagin Hall, 418 Curie Blvd., Philadelphia, PA 19104, Phone: 215-898-1799, FAX: 215-573-9193 or 215-573-5925.


* Alderfer MA, Navsaria N, Kazak AE. Family functioning and posttraumatic stress disorder in adolescent survivors of childhood cancer. Journal of Family Psychology. 2009;23(5):717–725. [PMC free article] [PubMed]
American Psychiatric Association. Diagnostic and statistical manual of mental disorders-text revision. 4. Washington, DC: Author; 2000.
* Barakat LP, Kazak AE, Meadows AT, Casey R, Meeske KA, Stuber ML. Families surviving childhood cancer: A comparison of posttraumatic stress symptoms with families of healthy children. Journal of Pediatric Psychology. 1997;22(6):843–859. [PubMed]
* Boyer BA, Hitelman JS, Knolls ML, Kafkalas CM. Posttraumatic stress and family functioning in pediatric spinal cord injuries: Moderation or mediation? American Journal of Family Therapy. 2003;31(1):23–37.
* Boyer BA, Ware CJ, Knolls ML, Kafkalas CM. Posttraumatic stress among families experiencing pediatric spinal cord injury: A replication. SCI Psychosocial Process. 2003;16(2):85–94.
Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.
* Brown RT, Madan-Swain A, Lambert RG. Posttraumatic stress symptoms in adolescent survivors of childhood cancer and their mothers. Journal of Traumatic Stress. 2003;16(4):309–318. [PubMed]
* Burton D, Foy DW, Bwanausi C, Johnson J. The relationship between traumatic exposure, family dysfunction, and post-traumatic stress symptoms in male juvenile offenders. Journal of Traumatic Stress. 1994;7(1):83–93. [PubMed]
Cauce AM, Ptacek JT, Mason C, Smith RE. Unpuhlished manuscript. University of Washington, Department of Psychology; Seattle: 1990. The social support rating scale-revised-SSRS: Three studies on development and validation.
* Connolly DM, McClowry S, Hayman L, Mahony L, Artman M. Posttraumatic stress disorder in children after cardiac surgery. Journal of Pediatrics. 2004;144:480–484. [PubMed]
* Dixon A, Howie P, Starling J. Trauma exposure, posttraumatic stress, and psychiatric comorbidity in female juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry. 2005;44(8):798–806. [PubMed]
Epstein NB, Baldwin I, Bishop D. The McMaster Family Assessment Device. Journal of Marital and Family Therapy. 1983;9:171–180.
Fischer L, Kokes RF, Ransom DC, Phillips SL, Rudd P. Alternative strategies for creating “relational” family data. Family Process. 1985;24:213–224. [PubMed]
Fisher L, Ransom DC, Terry HE. The California Family Health Project: VII. Summary and integration of findings. Family Process. 1993;32:69–86. [PubMed]
Foa E. Psychological processes related to recovery from a trauma and an effective treatment for PTSD. In: McFarlane A, Yehuda R, editors. Psychobiology of posttraumatic stress disorder. Vol. 821. New York: New York Academy of Sciences; 1997. pp. 410–424. [PubMed]
* Greenberg HS, Keane A. Risk factors for chronic posttraumatic stress symptoms and behavior problems in children and adolescents following a home fire. Child and Adolescent Social Work Journal. 2001;18(3):205–221.
* Halloran EC, Ross GJ, Carey MP. The relationship of adolescent personality and family environment to psychiatric diagnosis. Child Psychiatry & Human Development. 2002;32(3):201–216. [PubMed]
* Harris CA, Zakowski SG. Comparisons of distress in adolescents of cancer patients and controls. Psycho-Oncology. 2003;12(2):173–182. [PubMed]
Hobbie WL, Stuber M, Meeske K, Wissler K, Rourke MT, Ruccione K, et al. Symptoms of posttraumatic stress in young adult survivors of childhood cancer. Journal of Clinical Oncology. 2000;18(24):4060–4066. [PubMed]
Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson JP. Long-term posttraumatic stress disorder persists after major trauma in adolescents: New data on risk factors and functional outcome. Journal of Trauma. 2005;58(4):764–769. discussion 769–771. [PubMed]
Horowitz MJ. Stress response syndromes. 2. Northvale, NJ: Jason Aronson; 1986.
Kashy DA, Snyder DK. Measurement and data analytic issues in couple’s research. Psychological Assessment. 1995;7(3):338–348.
* Kasler J, Dahan J, Elias MJ. Relationship between sense of hope, family support, and post-traumatic stress disorder among children: The case of young victims of rocket attacks in Israel. Vulnerable Children and Youth Studies. 2008;3(3):182–191.
Kassam-Adams N. Introduction to the special issue: Posttraumatic stress related to pediatric illness and injury. Journal of Pediatric Psychology. 2006;31(4):337–342. [PubMed]
* Kazak AE, Barakat LP, Meeske K, Christakis D, Meadows AT, Casey R, et al. Posttraumatic stress, family functioning, and social support in survivors of childhood leukemia and their mothers and fathers. Journal of Consulting and Clinical Psychology. 1997;65(1):120–129. [PubMed]
Kazak AE, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer MA, Rourke MT. An integrative model of pediatric medical traumatic stress. Journal of Pediatric Psychology. 2006;31(4):343–355. [PubMed]
Kazak AE, Simms S, Barakat L, Hobbie W, Foley B, Golomb V, et al. Surviving cancer competently intervention program (SCCIP): A cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families. Family Process. 1999;38(2):175–191. [PubMed]
Kazak AE, McClure KS, Alderfer MA, Hwang WT, Crump TA, Le LT, et al. Cancer related beliefs: The family illness beliefs inventory (FIBI) Journal of Pediatric Psychology. 2004;27(7):531–542. [PubMed]
Kazak AE, Simms S, Alderfer MA, Rourke MT, Crump T, McClure K, et al. Feasibility and preliminary outcomes from a pilot study of a brief psychological intervention for families of children newly diagnosed with cancer. Journal of Pediatric Psychology. 2005;30(8):644–655. [PubMed]
Khamis V. Child Psychological Maltreatment in Palestinian families. Child Abuse & Neglect. 2000;24:1047–1059. [PubMed]
* Khamis V. Post-traumatic stress disorder among school age Palestinian children. Child Abuse & Neglect. 2005;29(1):81–95. [PubMed]
* Kiliç EZ, Özgüven HD, Sayil I. The psychological effects of parental mental health on children experiencing disaster: The experience of Bolu earthquake in Turkey. Family Process. 2003;42(4):485–495. [PubMed]
Kiser LJ, Black MM. Family processes in the midst of urban poverty: What does the trauma literature tell us? Aggression and Violent Behavior. 2005;10(6):715–750.
Knafl G, Dixon J, O’Malley J, Grey M, Deatrick J, Gallo A, et al. Analysis of cross-sectional univariate measurements for family dyads using linear mixed modeling. Journal of Family Nursing. 2009;15(2):130–151. [PMC free article] [PubMed]
Knafl K, Deatrick J, Gallo A, Dixon J, Grey M, Knafl G, O’Malley J. Assessment of the psychometric properties of the Family Management Measure. Journal of Pediatric Psychology. Advance access published on May 18, 2009, doi:10.1093/jpepsy/jsp043* (In Press)
* Koverola C, Proulx J, Battle P, Hanna C. Family functioning as predictors of distress in revictimized sexual abuse survivors. Journal of Interpersonal Violence. 1996;11(2):263–280.
Landgraf JM, Abetz L, Ware JE. The CHQ User’s Manual. Boston: Health Institute, New England Medical Center; 1996.
Langeland W, Olff M. Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature. Neuroscience and Biobehavioral Reviews. 2008;32(1):161–174. [PubMed]
* Laor N, Wolmer L, Cohen DJ. Mothers’ functioning and children’s symptoms 5 years after a SCUD missile attack. American Journal of Psychiatry. 2001;158(7):1020–1026. [PubMed]
* Linning LM, Kearney CA. Post-traumatic stress disorder in maltreated youth: A study of diagnostic comorbidity and child factors. Journal of Interpersonal Violence. 2004;19(10):1087–1101. [PubMed]
McCubbin HI, Patterson J, Bauman E, Harris L. Adolescent family inventory of life events (A-FILE) In: McCubbin HI, Thompson AI, McCubbin MA, editors. Family assessment: Resiliency, coping, and adaptation: Inventories for research and practice. Madison: University of Wisconsin System; 1996.
McCubbin HI, Patterson J, Wilson L. Family inventory of life events and changes (FILE) In: McCubbin HI, Thompson AI, McCubbin MA, editors. Family assessment: Resiliency, coping, and adaptation: Inventories for research and practice. Madison: University of Wisconsin System; 1996.
McFarlane AC. Family functioning and overprotection following a natural disaster: The longitudinal effects of post-traumatic morbidity. Australian and New Zealand Journal of Psychiatry. 1987;21:210–218. [PubMed]
Magaña AB, Goldstein JM, Karno M, Miklowitz DJ, Jenkins J, Falloon IR. A brief method for assessing expressed emotion in relatives of psychiatric patients. Psychiatric Research. 1986;17:203–212. [PubMed]
* Max JE, Castillo CS, Robin DA, Lindgren SD, Smith WL, Sato Y, et al. Posttraumatic stress symptomatology after childhood traumatic brain injury. Journal of Nervous and Mental Disease. 1998;186(10):589–596. [PubMed]
* Meiser-Stedman RA, Yule W, Dalgleish T, Smith P, Glucksman E. The role of the family in child and adolescent posttraumatic stress following attendance at an emergency department. Journal of Pediatric Psychology. Special Issue: Posttraumatic Stress Related to Pediatric Illness and Injury. 2006;31(4):397–402. [PubMed]
Miller IW, Kabacoff RI, Epstein NB, Bishop DS, Keitner GI, Baldwin LM, van der Spuy HIJ. The development of a clinical rating scale for the McMaster model of family functioning. Family Process. 1994;33(1):53–69. [PubMed]
Moos RH, Moos BS. Family environment Scale. Palo Alto: Consulting Psychologist Press, Inc; 1986.
National Child Traumatic Stress Network. Defining trauma and child traumatic stress. 2010. Retrieved May 25, 2010 from
National Institute of Health. Teen brains: Still under construction. 2005. Retrieved February 12, 2008, from
National Institute of Mental Health. Helping children and adolescents cope with violence and disasters: What community members can do. 2010. Retrieved September 21, 2010, from
Olson DH. Circumplex model VII: Validation studies and FACES III. Family Process. 1986;25:337–351. [PubMed]
Olson DH, Porter J, Bell RQ. FACES II. Family Adaptability and Cohesion Evaluation Scales. St. Paul: Family Social Science, University of Minnesota; 1982.
* Otto MW, Henin A, Hirshfeld-Becker DR, Pollack MH, Biederman J, Rosenbaum JF. Posttraumatic stress disorder symptoms following media exposure to tragic events: Impact of 9/11 on children at risk for anxiety disorders. Journal of Anxiety Disorders. 2007;21(7):888–902. [PubMed]
* Overstreet S, Dempsey M, Graham D, Moely B. Availability of family support as a moderator of exposure to community violence. Journal of Clinical Child Psychology. 1999;28(2):151–159. [PubMed]
* Ozono S, Saeki T, Mantani T, Ogata A, Okamura H, Yamawaki S. Factors related to posttraumatic stress in adolescent survivors of childhood cancer and their parents. Supportive Care in Cancer. 2007;15(3):309–317. [PubMed]
Parker G. Parental overprotection: A risk factor in psychosocial development. New York: Grune Stratton; 1983.
* Pelcovitz D, Libov BG, Mandel FS, Kaplan SJ, Weinblatt M, Septimus A. Posttraumatic stress disorder and family functioning in adolescent cancer. Journal of Traumatic Stress. 1998;11(2):205–221. [PubMed]
Pynoos RS, Steinberg AM, Ornitz EM, Goenjian AK. Issues in the developmental neurobiology of traumatic stress. Annals of New York Academy of Science. 1997;821:176–193. [PubMed]
Pynoos RS, Steinberg AM, Piacentini JC. A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry. 1999;46:1542–1554. [PubMed]
Rosenbaum JF, Biederman J, Hirshfeld DR, Bolduc EA, Faraone SV, Kagan J, et al. Further evidence of an association between behavioral inhibition and anxiety disorders: results from a family study from a non-clinical sample. Journal of Psychiatry Research. 1991;25:49–65. [PubMed]
Rosenbaum JF, Biederman J, Hirshfeld-Becker DR, Kagan J, Snidman N, Friedman D, et al. A controlled study of behavioral inhibition in children of parents with panic disorder and depression. American Journal of Psychiatry. 2000;157:2002–2010. [PubMed]
Ruchkin V, Schwab-Stone M, Jones S, Cicchetti DV, Koposov R, Vermeiren R. Is posttraumatic stress in youth a culture-bound phenomenon? A comparison of symptom trends in selected U.S. and Russian communities. American Journal of Psychiatry. 2005;162:538–544. [PubMed]
Scheeringa MS, Wright MJ, Hunt JP, Zeanah CH. Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. American Journal of Psychiatry. 2006;163(4):644–651. [PubMed]
* Schreier H, Ladakakos C, Morabito D, Chapman L, Knudson MM. Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: A longitudinal examination of symptom prevalence, correlates, and parent-child symptom reporting. Journal of Trauma-Injury Infection & Critical Care. 2005;58(2):353–363. [PubMed]
Smilkstein G. A proposal for a family function test and its use by physicians. Journal of Family Practice. 1978;6(6):1231–1239. [PubMed]
Stehl ML, Kazak AE, Alderfer MA, Rodriguez A, Hwang WT, Paj ALH, et al. Conducting a randomized clinical trial of an psychological intervention for parents/caregivers of children with cancer shortly after diagnosis. Journal of Pediatric Psychology. 2009;34(8):803–816. [PMC free article] [PubMed]
Terr LC. Childhood traumas: an outline and overview. American Journal of Psychiatry. 1991;148(1):10–20. [PubMed]
Uphold CR, Strickland OL. Issues related to the unit of analysis in family nursing research. Western Journal of Nursing Research. 1989;11(4):405–417. [PubMed]
van der Kolk BA. The neurobiology of childhood trauma and abuse. Child and Adolescent Psychiatric Clinics of North America. 2003;12(2):293. [PubMed]
van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: The complexity of adaptation to trauma. American Journal of Psychiatry. 1996;153(7):83–93. [PubMed]
* Zatzick DF, Jurkovich GJ, Fan M-Y, Grossman DC, Russo JE, Katon WJ, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Archives of Pediatrics and Adolescent Medicine. 2008;162(7):642–648. [PubMed]
Zimet GD, Powell SS, Farley GK, Werkman S, Berkoff KA. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment. 1990;55(3/4):610–617. [PubMed]